MALARIA: Roadmaps are a good tool - but we must stay on the road

Bill Brieger : 16 May 2011

Off-Road in Uganda
Uganda’s 2010 Roll Back Malaria Roadmap seemed reassuring. Apparently 2.7m nets were already in place by late 2009, and supposedly a supply of another 18m long lasting nets (or at least the funding) was ready for achieving universal coverage by December 2010.
Assessment of Uganda’s Roadmap progress credited the country with achieving procurement of these nets. It seems odd therefore that the 2011 Roadmap indicates that 6.4m nets are in place and 10.4m need to be distributed in 2011. What’s going on?
A new study by Carla Proietti and colleagues provides some answers. Not only do they document continued high transmission in the northern part of Uganda (polymerase chain reaction rate of 72% in children below five year of age), a situation that threatens control efforts by neighbors, but they also identify plausible reasons for the lag.
The researchers politely suggest that, “The failure to reduce the burden of malaria could reflect sub-optimal implementation of malaria control measures.” They also explained that, “Malaria control efforts in Apac (sub-county) were not reliably monitored in the last decade and affected by political unrest in preceding years.”
Stockouts of anti-malarial ACTs was also listed as a problem. It should be recalled a few years ago that, “The Global Fund has decided to suspend its five grants to Uganda because there is evidence of serious mismanagement by the Project Management Unit (PMU) for Global Fund grants in Uganda.” Although the programs have resumed, satisfactory settlement of the problem was not achieved.
In light of this study Childsurvival.net warns us not to let successes in recent years blind us to reality. “Those who believe that Africa is within shooting distance of malaria elimination may wish to reconsider their position after reading this article (Proietti et al.). One should qualify this Ugandan article in several ways: 1) Local insurgency in the area under consideration, 2) Hiccoughs with the GF over misappropriation of resources, 3) Autocratic gerontocracy at the national level. Unfortunately, these three factors are not peculiar to Uganda.”
 Roadmaps are a good tool to help us plan for malaria control and elimination - but we must stay on the road for them to work.

http://www.malariafreefuture.org/blog/?p=1203

MALARIA: Factors affecting treatment-seeking for febrile illness in a malaria endemic block

Factors affecting treatment-seeking for febrile illness in a malaria endemic block in Boudh district, Orissa, India: policy implications for malaria control
Ashis Das and TK Sundari Ravindran : Malaria Journal 2010, 9:377

Background
Orissa state in eastern India accounts for the highest malaria burden to the nation. However, evidences are limited on its treatment-seeking behaviour in the state. We assessed the treatment-seeking behaviour towards febrile illness in a malaria endemic district in Orissa.

Methods
A cross-sectional community-based survey was carried out during the high malaria transmission season of 2006 in Boudh district. Respondents (n=300) who had fever with chills within two weeks prior to the day of data collection were selected through a multi-stage sampling and interviewed with a pre-tested and structured interview schedule. Malaria treatment providers (n=23) were interviewed in the district to gather their insights on factors associated with prompt and effective treatment through a semi-structured and open-ended interview guideline.

Results
Majority of respondents (n=281) sought some sort of treatment e.g. government health facility (35.7%), less qualified providers (31.3%), and community level health workers and volunteers (24.3%). The single most common reason (66.9%) for choosing a provider was proximity. Over a half (55.7%) sought treatment from appropriate providers within 48 hours of onset of symptoms. Respondents under five years (OR 2.00, 95% CI 0.84-4.80, P = 0.012), belonging to scheduled tribe community (OR 2.13, 95% CI 1.11-4.07, P = 0.022) and visiting a provider more than five kilometers (OR 2.04, 95% CI 1.09-3.83, P = 0.026) were more likely to have delayed or inappropriate treatment. Interviews with the providers indicated that patients' lack of trust in community volunteers providing treatment led to inappropriate treatment-seeking from the less qualified providers. The reasons for the lack of trust included drug side effects, suspicions about drug quality, stock-outs of drugs and inappropriate attitude of the provider.
Conclusion
Large-scale involvement of less qualified providers is suggested in the malaria control programme as volunteers after appropriate capacity development since the community has more trust in them. This should be supported by uninterrupted supply of drugs to the community volunteers, and involvement of the community-based organizations and volunteers in the planning, implementation, and monitoring of malaria control services. There is also a need for continuous and rigorous impact evaluations of the program to make necessary modifications, scale up and to prevent drug resistance.
http://www.malariajournal.com/content/9/1/377

MALARIA: Large-Scale Malaria Treatment in the Private Sector:

EXECUTIVE SUMMARY
Population Services International/Cambodia (PSI/Cambodia) was established in 1993 to address child survival (safe water and diarrhea treatment), HIV/AIDS, malaria, and reproductive health needs among women of child-bearing age, caretakers of children under five, and high-risk groups including commercial sex workers and men who have sex with men. Following a successful pilot in 2002, in 2003 PSI/ Cambodia established an initiative to provide branded malaria treatment through private clinics, pharmacies, and shops across most of rural Cambodia. By 2009 this program provided half of all malaria treatment in the country and 75% of all artesunate and mefloquine (AS/MQ) distributed.1 Cambodia was the first country to pilot and then scale-up the provision of subsidized ACTs in the private sector.

The PSI/Cambodia malaria program sells a branded version of the same ACT supported by Cambodia’s National Malaria Control Program, known as “CNM.” PSI/Cambodia imports the ACTs directly into its Phnom Penh warehouse before distributing them to three regional PSI depots. PSI-employed sales representatives make monthly sales calls to 1,737 private outlets. 500 of these are clinicianor pharmacy-operated facilities that are also visited once per month by PSIemployed medical detailers who provide training, counseling, and support on the appropriate use of ACTs, malaria test kits, and other medicines.

Stock outs have been a major problem for the program since inception. The primary causes of stock outs have been changes in the approval status of manufacturers, and long procurement timelines often associated with donor delays which have hindered the arrival of ACTs into Cambodia. Because of PSI/Cambodia’s
in-house management of the in-country supply chain, no stock outs have been reported resulting from breakdowns of the supply chain within Cambodia; breaks have all been the result of delays in the procurement of Malarine into Cambodia and affect both the public and private sector’s ability to deliver.

ACTs sold through the PSI/Cambodia program are highly subsidized, and are sold to private outlets at an average price of $0.29,2 with a recommended average price to-patients of $0.45.3 In practice, the price of Malarine to patients has been documented to vary considerably, ranging between $0.82 and $1.18.4 This price volatility and overcharging appears to be due primarily to fluctuations in the supply of ACTs.
http://www.globalhealthsciences.ucsf.edu/pdf/GHG-Cambodia-Case-Study.pdf